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Sustainable practice change. Professionals' experiences with a multisectoral child health promotion programme in Sweden.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-0001-8944-2558
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-0002-8184-6360
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2011 (English)In: BMC Health Services Research, ISSN 1472-6963, Vol. 11, no 1, 61- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: New methods for prevention and health promotion and are constantly evolving; however, positive outcomes will only emerge if these methods are fully adopted and sustainable in practice. To date, limited attention has been given to sustainability of health promotion efforts. This study aimed to explore facilitators, barriers, and requirements for sustainability as experienced by professionals two years after finalizing the development and implementation of a multisectoral child health promotion programme in Sweden (the Salut programme). Initiated in 2005, the programme uses a 'Salutogenesis' approach to support health-promoting activities in health care, social services, and schools.

METHODS: All professionals involved in the Salut Programme's pilot areas were interviewed between May and September 2009, approximately two years after the intervention package was established and implemented. Participants (n=23) were midwives, child health nurses, dental hygienists/dental nurses, and pre-school teachers. Transcribed data underwent qualitative content analysis to illuminate perceived facilitators, barriers, and requirements for program sustainability.

RESULTS: The programme was described as sustainable at most sites, except in child health care. The perception of facilitators, barriers, and requirements were largely shared across sectors. Facilitators included being actively involved in intervention development and small-scale testing, personal values corresponding to programme intentions, regular meetings, working close with collaborators, using manuals and a clear programme branding. Existing or potential barriers included insufficient managerial involvement and support and perceived constraints regarding time and resources. In dental health care, barriers also included conflicting incentives for performance. Many facilitators and barriers identified by participants also reflected their perceptions of more general and forthcoming requirements for program sustainability.

CONCLUSIONS: These results contribute to the knowledge of processes involved in achieving sustainability in health promotion initiatives. Facilitating factors include involving front-line professionals in intervention development and using small scale testing; however, the success of a program requires paying attention to the role of managerial support and an overall supportive system. In summary, these results emphasise the importance for both practitioners and researchers to pay attention to parallel processes at different levels in multidisciplinary improvement efforts intended to ensure sustainable practice change.

Place, publisher, year, edition, pages
BioMed Central , 2011. Vol. 11, no 1, 61- p.
National Category
Health Sciences
URN: urn:nbn:se:umu:diva-41699DOI: 10.1186/1472-6963-11-61PubMedID: 21426583OAI: diva2:407618
Available from: 2011-03-31 Created: 2011-03-31 Last updated: 2015-04-29Bibliographically approved
In thesis
1. Health promotion in pregnancy and early parenthood: the challenge of innovation, implementation and change within the Salut Programme
Open this publication in new window or tab >>Health promotion in pregnancy and early parenthood: the challenge of innovation, implementation and change within the Salut Programme
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: In 2005, the Västerbotten County Council launched a child health promotion programme, “the Salut Programme”, in response to an alarming prevalence of overweight and obesity, and trends of increased dental caries, among young county citizens. The programme, initially developed in four pilot areas, is built on multidisciplinary and cross-sectoral collaboration and aims to support and strengthen health promotion activities in health care, social services and school settings. It targets children and adolescents (0-18 years of age) and their parents, and starts during pregnancy. This thesis focuses on interventions provided by antenatal care, child health care, dental services, and open pre-schools, directed to expectant parents and families with children aged 0-1 ½ years. Within the programme context, the aim was to explore socio-demographic patterns of overweight and obesity in expectant parents (Paper I), firsttime parents’ experiences of health promotion and lifestyle change during pregnancy and early parenthood (Paper II), professionals’ experiences of factors influencing programme implementation and sustainability (Paper III and IV), and early programme outcomes on professionals’ health promotion practices and collaboration following countywide dissemination and implementation (Paper IV).


Methods and results: A population based cross-sectional study among expectant parents showed overweight and obesity in 29% of women (pre-pregnancy) and in 53% of men (n=4,352♀, 3,949♂). The likelihood for obesity was higher in expectant parents with lower levels of education, among those unemployed or on sick leave, and those living in rural areas. In 62% of couples, at least one of the partners was overweight or obese; a positive partner correlation was also found for BMI (I). An interview study with 24 first-time parents (n=12♀, 12♂) revealed that they primarily undertook lifestyle changes to secure the health of the fetus in pregnancy, and to provide a healthy environment in childhood. Parents described themselves as highly receptive to information about how their lifestyle could influence fetal health, and they frequently discussed pregnancy risks related to tobacco and alcohol, as well as toxins and infectious agents in foods. However, parents did not seem inclined to make lifestyle changes primarily to promote their own health. The antenatal and child health care services were perceived as being mainly directed towards women, and parents described a lack of a holistic view of the family which included experiences of fathers being treated as less important (II). An interview study undertaken with professionals (n=23) in the Salut Programme pilot areas indicated programme sustainability at most sites, two years after implementation, although less adherence was described within child health care. Factors influencing programme sustainability, as described by professionals, were identified at multiple organisational levels (III). A before-and-after survey among professionals (n=144) measured outcomes of the county-wide implementation of the Salut Programme in 13 out of 15 county municipalities. Results showed significant improvements in professionals’ health promotion practices and collaboration across sectors. A number of important implementation facilitators and barriers, acting at different organizational levels, were also identified via a survey comprised of open-ended questions (IV).


Conclusion: The Salut Programme, developed with high involvement of professionals, and strongly integrated in existing organisational structures and practices, shows potential for improving health promotion practices and cross-sectoral collaboration. The findings can inform further development of the Salut well as new health promotion initiatives, and inform policy practice and future research. These aspects include approaches in health promotion and prevention, father involvement during pregnancy and early parenthood, and factors influencing implementation and sustainability of cross-sectoral health promotion programmes.

Abstract [sv]

Bakgrund: År 2005 lanserade Västerbottens läns landsting en hälsofrämjande satsning “Salut” som svar på en oroande förekomst av övervikt och fetma samt trender till ökad förekomst av karies hos barn i länet. Satsningen, som initialt utvecklades i fyra pilotområden, bygger på tvärprofessionellt och verksamhetsövergripande samarbete och syftar till att stödja och stärka hälsofrämjande insatser inom landstinget och länets kommuner. Satsningen riktar sig till barn och unga (0-18 år) och deras föräldrar, med start under graviditeten. Denna avhandling fokuserar på insatser som erbjuds via mödrahälsovård, barnhälsovård, tandvård och öppen förskola riktade till blivande föräldrar och familjer med barn i åldern 0-1 ½ år. Med utgångspunkt från Salut-satsningen syftar avhandlingen till att undersöka socio-demografiska mönster av övervikt och fetma hos blivande föräldrar (I), förstagångsföräldrars upplevelser av hälsofrämjande insatser och förändrade levnadsvanor under graviditet och tidigt föräldraskap (II), personalens upplevelser av underlättande och hindrande faktorer för satsningens införande och uthållighet (III, IV), samt förändringar i arbetssätt och samarbete mellan verksamheterna efter den länstäckande spridningen av satsningen (IV).


Metod och resultat: En populationsbaserad tvärsnittsstudie bland blivande föräldrar visade på övervikt och fetma hos 29% av kvinnorna (vikt före graviditet) och hos 53% av männen (n=4352♀, 3949♂). Lägre utbildningsnivå, arbetslöshet och sjukskrivning samt att bo utanför städerna visade sig öka sannolikheten för fetma. Hos en övervägande del av paren (62%) fanns minst en partner med övervikt eller fetma och samband kunde även påvisas mellan kvinnans och mannens BMI (I). En intervjustudie med 24 förstagångsföräldrar (n=12♀, 12♂) visade att föräldrarna främst förändrade sina levnadsvanor för att säkra hälsan hos fostret under graviditeten och för att skapa en hälsosam miljö för barnet under uppväxten. Föräldrarna beskrev sig själva som mycket mottagliga för information om hur deras levnadsvanor kunde påverka fostrets hälsa och de diskuterade ofta graviditetsrisker i relation till tobak och alkohol samt gifter och smittoämnen i livsmedel. Föräldrarna var dock mindre angelägna att förändra sina levnadsvanor med tanke på sin egen hälsa. De upplevde att mödrahälsovårdens och barnhälsovårdens insatser i huvudsak riktades till kvinnor och beskrev en avsaknad av helhetssyn på familjen, vilket även avspeglades i upplevelser av att papporna behandlades som mindre viktiga (II). En intervjustudie med personal (n=23) inom pilotområdena, två år efter utveckling och införandet av Saluts insatser, indikerade god uthållighet av satsningen, även om en lägre följsamhet till insatserna beskrevs inom barnhälsovården. Faktorer som av personalen beskrevs påverka uthålligheten identifierades på flera organisatoriska nivåer (III). En före- och efterstudie bland personal (n=144) mätte effekter av den länstäckande spridningen av satsningen i 13 av länets 15 kommuner. Resultaten visade på flera signifikanta förbättringar av de hälsofrämjande arbetssätten och ett ökat samarbete mellan verksamheterna. En enkät med öppna frågor riktad till personalen belyste också faktorer på flera organisationsnivåer som ansågs underlätta respektive hindra införandeprocessen (IV).


Slutsats: Salut-satsningen, som är utvecklad i nära samarbete med verksamheternas personal och väl integrerad i redan existerande organisatoriska strukturer och arbetssätt, visar på potential att förbättra hälsofrämjande arbetssätt och samarbete mellan verksamheter. Aspekter som beskrivits och diskuterats kan vägleda satsningens fortsatta utveckling såväl som framtida nya initiativ. Resultaten och slutsatserna kan även användas i syfte att påverka policy, praxis och framtida forskning. Detta avser framförallt hälsofrämjande och sjukdomsförebyggande metoder, pappans roll under graviditet och tidigt föräldraskap samt kunskaper om faktorer som kan ha betydelse för genomförande och uthållighet av verksamhetsövergripande hälsofrämjande insatser.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet, 2013. 94 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1570
Antenatal care, Child health care, Counselling, Dental health services, Dissemination, Health Promotion, Implementation, Intervention, Parents, Pregnancy, Prevention, Obesity, Overweight, Pre-­school, Primary Health Care, Sustainability
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health; Epidemiology
urn:nbn:se:umu:diva-70172 (URN)978-­91-­7459-­641-­0 (PDF) (ISBN)978-91-7459-640-3 (Print) (ISBN)
Public defence
2013-05-31, Betula, byggnad 6 M, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Available from: 2013-05-08 Created: 2013-05-06 Last updated: 2015-04-29Bibliographically approved

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